management of knee ligament injuries

1. MANAGEMENT OF KNEE LIGAMENT INJURIES
BY
DR OBIAKO B. C.
MODERATOR: DR EDE . O
15/06/22

2. Learning Objectives
• To identify the types of ligament injuries affecting the knee
 To identify the aetiology and mechanism of knee ligament
injuries
 To understand the clinical evaluation of a patient with knee
ligament injury
 To understand the investigations and treatment of knee
ligament injuries

3. OUTLINE
Learning Objectives
Introduction
Relevant Anatomy
Epidemiology
Aetiology
Management: Resuscitation
History
Physical examination
Investigations
Treatment
Complications
Prognosis
Take home Message
Conclusion

4. INTRODUCTION
Ligament injuries are among the most common causes of
musculoskeletal joint pain and disability
Knee ligament injury is a common problem
A high index of suspicion is required to clinch the diagnosis
Appropriate management is required to prevent the functional loss
associated with it.
Such management may be nonoperative or operative depending on the
cause.
Appropriate rehabilitation is also required to improve functional
outcome

5. RELEVANT ANATOMY
The commonly injured ligaments of the knee include:
The Anterior Cruciate Ligament (ACL)
Posterior Cruciate Ligament (ACL)
Medial collateral( MCL)/Posteromedial corner(PMC)
Lateral collateral (LCL)/ Posterolateral corner (PLC)

6. RELEVANT ANATOMY
ACL:
Femoral attachment : PM edge of
the lateral femoral condyle,
posterior to the lateral intercondylar
ridge
Tibial attachment: Anterior tibia,
between intercondylar eminences
Anteromedial and posterolateral
bundles
Resists anterior translation of the
tibia (anteromedial ) and for
rotational stability (posterolateral)

7. RELEVANT ANATOMY
PCL:
From the posterior tibial sulcus
From the lateral border of medial
femoral condyle
50% larger than the ACL at femoral
insertion and 20% larger at tibial
insertion
Anterolateral and posteromedial
bundles
Resists posterior translation of the
tibia

8. RELEVANT ANATOMY
MCL/POSTEROMEDIAL CORNER:
MCL :
Arises from the medial aspect of the
femur
proximal and posterior to the medial
femoral epicondyle
attaches anterior to the posteromedial
tibial crest and distal to the medial
tibial plateau
o Superficial MCL
 Deep MCL:Meniscofemoral
Meniscotibial
Secondary restraint to valgus stress
(4-8% restraint)

9. RELEVANT ANATOMY
MCL/POSTEROMEDIAL CORNER:
PMC:
Lies deep to MCL
Formed by:
Insertion of semimembranosus
Posterior oblique ligament
oblique popliteal ligament
posterior capsule
Resists valgus and external rotation
loads

10. RELEVANT ANATOMY
LCL/POSTEROLATERAL CORNER
LCL:
Attachments
Lateral femoral
condyle posterior and superior to origin
of popliteus
Anterior to the popliteofibular ligament
on the fibula
LCL is the primary stabilizer to varus stress
and secondary restraint to posterior
translation of the tibia

11. RELEVANT ANATOMY
LCL/POSTEROLATERAL CORNER
PLC
Formed by:
LCL (295N)
popliteus muscle and tendon (680N)
popliteofibular ligament (229N)
Lateral capsule
Arcuate ligament
Iliotibial band
Fabellofibular ligament
PLC resists varus and external rotation

12. RELEVANT ANATOMY
Other knee ligaments:
Medial patellofemoral
ligament: Lateral
translation of patella
Anterolateral ligament:
Rotational stability

13. EPIDEMIOLOGY
ACL INJURY:
Annual incidence 35 per 100,000
2-8 times more in females than males
(greater valgus knee, increased
quadriceps-to hamstring strength,
smaller ligaments, greater generalized
ligament laxity)
70% are sports related :football,
basketball and tennis
About 50% have associated meniscal
and other ligament injuries
PCL INJURY:
5-20% of all knee ligament
injuries
Not as common as ACL
injury(PCL wider and
stronger than ACL)

14. EPIDEMIOLOGY
MCL INJURY:
commoner in males
MCL injuries occur in approximately
25% of cases
Concomitant injuris seen with ACL in
95% of cases
Also associated with medial meniscal
injury
LCL/POSTEROLATERAL CORNER
INJURY:
Account for 7-16% of all knee
ligament injuries
25% of PLC injuries are isolated
ligament injuries
Assoc. with PLC, ACL, PCL injuries
• Lack of recognition of a PLC injury
has been cited as a common cause
of ACL reconstruction failure
12 – 29% with peroneal nerve palsy

15. AETIOLOGY/MECHANISM
PCL

16. AETIOLOGY/MECHANISM
ACL PCL MCL/P
MC
LCL
Mechanism non-contact
pivoting
injury
tibia translates
anteriorly
while knee is
in slight
flexion and
valgus
blow to
the lateral
aspect of the
knee
Posteriorly directed
force to the proximal
tibia(Dashboard
injury) with the knee
flexed
Noncontact
hyperflexion with a
planterflexed foot
Hyperextension
Direct
blow to
lateral
aspect of
the knee
Non
contact
rotationa
l injury
Direct blow to
the inner side
of the knee
With knee in
extension

17. MANAGEMENT
Early or late presentation
ATLS Protocol
Primary survey and resuscitation
Analgesics
Splinting
Secondary Survey
History
Detailed Physical Examination
Investigation
Treatment

18. MANAGEMENT:HISTORY
Biodata: Occupation
PC/HPC:
Mechanism
Pain(onset, duration,
severity)
Swelling
Giving away

19. MANAGEMENT:HISTORY
PMH:
Previuos hx of instability
FSH:
Family hx of ligamentous
laxity

20. MANAGEMENT:PHYSICAL
EXAMINATION
Quadriceps wasting
Gait
Swelling
Point Tenderness
Effusion
Reduced ROM
Neurovascular examination

21. MANAGEMENT:PHYSICAL
EXAMINATION
ACL INJURY:
Anterior drawer’s test
Lachman’s test
(most sensitive)

22. MANAGEMENT:PHYSICAL
EXAMINATION
ACL INJURY:
Pivot shift test
(most specific)
Knee brought from extension
(anteriorly subluxated) to
flexion (reduced) with valgus
and internal rotation of tibia
Reduces at 20-30° of flexion
due to IT band tension

23. MANAGEMENT:PHYSICAL
EXAMINATION
PCL INJURY:
The Posterior drawer’s
Positive quadriceps active test
Patient is placed supine
knee flexed at 90° with the
foot flat on the bed
Contraction of quadriceps
moves tibia forwards by up to
2mm

24. MANAGEMENT:PHYSICAL
EXAMINATION
PCL INJURY:
Posterior sag sign

25. MANAGEMENT:PHYSICAL
EXAMINATION
MCL/PMC INJURY:
Valgus stress

26. MANAGEMENT:PHYSICAL
EXAMINATION
MCL severity:
Grade
Grade I:1-4mm
Grade II: 5-9mm
Grade III:≥ 10mm
Degree
I – tenderness, no instability
II – valgus laxity with firm
end point
III – Mushy or absent end
point

27. MANAGEMENT:PHYSICAL
EXAMINATION
Classification of MCL injury by Hughston

28. MANAGEMENT:PHYSICAL
EXAMINATION
PMC INJURY:
slocum test
Rationale: disruption of the deep MCL
allows the meniscus to move freely and
allows the medial tibial plateau to rotate
anteriorly
The Slocum test is helpful to examine
PMC injuries.
The tibia is externally rotated 15 with the
knee flexion at 90, and the tibia is once
pulled forward to determine the
excessive anterior rotation of the medial
tibial plateau.
Asymmetric increased translation helps
to identify injuries of posterior oblique
ligament and posteromedial capsule.

29. MANAGEMENT:PHYSICAL
EXAMINATION
LCL/PLC INJURY:
Varus stretch test
0⁰ : isolated LCL
20⁰ of flexion: ACL,PCL,PLC
Grade I : 0-5mm
Grade II : 5-10mm
Grade III: >10mm
Dial Test: Degree of external rotation
Diff of >10⁰ external rotation
At 30⁰ : isolated PLC
90⁰ : Assoc PCL

30. MANAGEMENT:PHYSICAL
EXAMINATION
LCL/PLC INJURY:
External rotation recurvatum test
Lift toes with knee in full extension
Positive : hyperextension and external tibial
rotation
Reverse pivot shift test
Start – knee flexed 90°
Slowly extend knee with axial load and valgus
stress.
Foot in external rotation
Tibia is subluxed
Will jump or reduce at 20-30° of flexion
IT band changes from flexor to extensor at this
angle

31. MANAGEMENT:PHYSICAL
EXAMINATION
PLC INJURY:
Posterolateral Drawer’s Test
Performed with the hip flexed 45°,
knee flexed 80°, and foot is ER 15°.
posterior drawer and external
rotation force increase in
posterolateral translation (lateral tibia
externally rotates relative to lateral
femoral condyle)
30⁰ :PLC
90⁰ :PCL
Graded I : 1-5mm
Graded II: 5-10mm
Graded III: >10mm

32. MANAGEMENT: INVESTIGATIONS
ACL INJURY:
XRAY: Segond fracture
Bony avulsion by the anterolateral
ligament (ALL)
Associated with ACL tear 75-100%
of the time
Tibial spine avulsion
MRI:
Discontinuity of fibers on T2
Abnormal orientation
Non-visualization of ACL

33. MANAGEMENT: INVESTIGATIONS
ACL INJURY:
MRI:

34. MANAGEMENT:INVESTIGATIONS
PCL INJURY:
XRAY:
Bony avulsion at tibial insertion
of PCL
posterior sag of the tibia
Stress radiographs
Displacement
> 8mm complete PCL rupture
>12 mm other assoc. ligamentous
injury

35. MANAGEMENT:INVESTIGATIONS
LCL/PLC INJURY:
Fibular head avulsion
(acuate sign)
Avulsion of gerdy’s
tubercle
Tibial plateau fracture

36. MANAGEMENT: INVESTIGATIONS
MCL/PMC INJURY:
X-ray:
Peligrini steida lesion
avulsion of medial femoral
condyle
Calcification at the femoral origin
of MCL
Stress radiographs
MRI:
proximal, mid substance, or distal
Deep and/or superficial ligament is
disrupted
Collateral ligament is best visualized
on T2

37. MANAGEMENT: TREATMENT
General considerations
Depends on the ligament involved
Nonoperative: physiotherapy
crutch mobilization
Operative:

38. MANAGEMENT: TREATMENT
Primary repair vs. reconstruction
Early vs. late repair
Open vs. arthroscopic repair
Autologous vs. allograft
Anatomical vs. non anatomical repair
Single vs. double bundle reconstruction

39. MANAGEMENT: TREATMENT
Generaral Operative principles
Examination under anesthesia
Graft harvesting/preparation
Diagnostic scope
Debridement
Pin placement
Femoral tunnel
Tibial tunnel
Tunnel reaming
Graft passage
Graft fixation

40. MANAGEMENT: TREATMENT
Advantages of autograft
Uses patient's own tissue
Most common source of graft
Faster incorporation
Less immune reaction
No infection transmission
Allograft pros & cons
Useful in revisions with
increased bulk
No Donor site morbidity
Longer incorporation time
More expensive
Risk of disease transmission and
rejection
Risk of re-rupture in young
athletes

41. MANAGEMENT: TREATMENT
Bone-patella-bone autograft
Longest history of use and considered
the "gold standard“
Bone to bone healing leads to faster
incorporation time
Ability to rigidly fix the joint line
(screws)
Highest incidence of anterior knee pain
(up to 10-30%) and kneeling pain
maximum load to failure is 2600
Newtons (intact ACL is 1725 Newtons)
Quadriceps tendon autograft
small incision in area that does not see
pressure during kneeling
Does not involve physis
Maximum load to failure 2185 Newtons
Similar patient-reported and functional
outcomes as other autografts
May include bone block or completely
soft tissue
Less commonly used so is often available
in revision setting

42. MANAGEMENT: TREATMENT
Ideal graft properties
Strong
Secure fixation
Easy to pass
Readily available
Low donor site morbidity

43. MANAGEMENT: TREATMENT
ACL INJURY:
Depends on age, activity level, presence
of arthritis and patient’s desire
Nonoperative: inactive patients
Physiotherapy
modify activity
PRICES
functional bracing
splints, crutches
100% at 9-12months
Operative: Active patients
failure of nonoperative
treatment
Recurrent instability
Associated injuries( meniscal)
100% at 6-12 months
Noyes et al 1/3 will return without surgery,
1/3 will require bracing , 1/3 will require
surgery

44. MANAGEMENT: TREATMENT
ACL surgical Treatment:
ACL repair: high failure rates
ACL reconstruction:
Autologous or allograft
Autologous:
Patella tendon bone graft
Hamstring(semitendinosus and gracilis )
Quadriceps tendon
Graft fixation
interference screws (aperture/compression
fixation)
cortical buttons (suspensory fixation)
screw and washer post (suspensory fixation)
staple (suspensory fixation)

45. MANAGEMENT: TREATMENT
ACL INJURY: Rehabilitation
Aim: control pain
oedema
protect graft
Crutches with weight bearing as tolerated
Quadriceps strengthening
Flexion of at least 100 degrees
RCT shows that bracing does has no
effect on pain reduction, ROM, graft
stability or rate of reinjury
Cryotherapy reduces pain and swelling
Return to activity depends on subjective
and objective assessment

46. MANAGEMENT: TREATMENT
PCL INJURY:
Healing potential higher (better synovial
coverage)
Depends on severity and presence of concomitant
injuries
Operative
Indications : concomitant injuries
Graft options; Autologous or allograft
Graft fixed in 20deg of flexion
PCL with assoc lig injury: no consensus
initial nonoperative

47. MANAGEMENT:TREATMENT
PCL INJURY: Rehabilitation
Immobilized in extension post op
Longer and slower than for ACL
reconstruction
ROM excercises in prone max of 90deg of
flexion
Bracing for surgically reconstructed grade
III injury
Hamstrings excercises after 6weeks
Resume low impact activities at 12weeks
Running at 6months post op
All activity at 12months
For non operated group resumption of
activity at 6-8weekks

48. MANAGEMENT: TREATMENT
LCL/PLC INJURY:
Nonoperative: Grade I or II
Protected weight bearing
Physiotherapy
Operative: complete injuries
Avulsions
Concomitant ACL/PCL injury
Primary repair:
Reconstruction:
autologous(hamstring) or
allograft(cadaver)
anatomic or non anatomic repair

49. MANAGEMENT:TREATMENT
Non-anatomic:
Biceps tenodesis,
arcuate copmlex/proximal
bone block advancments
IT band sling
Augments
Anatomic
Fibular-based vs. tibial-
fibular-based

50. MANAGEMENT: TREATMENT
LCL :
Biceps tenodesis:
Replaces LCL & PFL
Band of distal biceps
femoris tendon is attached
to lateral femoral
epicondyle

51. MANAGEMENT:TREATMENT
LCL:
Bone –PT-Bone Allograft.

52. MANAGEMENT:TREATMENT
LCL reconsruction
Tib-fib-based
More closely resembles
anatomy
No evidence of improved
outcomes
More technically demanding
LaPrade technique
Reconstructs LCL, PFL, and
popliteus tendon
2 tendon grafts

53. MANAGEMENT:TREATMENT
LCL/PLC INJURY:
Rehabilitation
Rigid brace for 4-6weeks post op
ROM excercises
Quadriceps strengthening
Hamstring exercise from
4months post op
Return to sports/activity at 6-
12months

54. MANAGEMENT: TREATMENT
MCL/PMC INJURY:
Nonoperative:
most isolated Grade I and II
Knee brace for 4 weeks
Crutches if injury is severe
Holden et al treated 51
footballers with grade I
and II MCL injury 80%
return to sport in average
of 21 days
Surgical treatment:
Isolated grade III with persistent
instability
Grade III injury with valgus
laxity in full extension
MCL with associated 1 or more
ligament injuries

55. MANAGEMENT: TREATMENT
MCL/PMC INJURY:
Graft options:
semitendinosus autograft
hamstring
Tibialis anterior or achilles
tendon allograft
Ligament avulsions should be
reattached with suture anchors
in 30 degrees of flexion
Post op knee in varus ad
extension

56. MANAGEMENT: TREATMENT
MCL/PMC INJURY:
Rehabilitation
Quadriceps strengthening
excercises
Return to activity depends on
grade
Grade I: 5-7days Grade
II:4-6weeks Grade III: 6-
8weeks

57. MANAGEMENT: TREATMENT

58. MANAGEMENT: TREATMENT
MULTIPLE-LIGAMENT KNEE INJURIES
Complete or partilal rupture of both
cruciates and additional injury to either
the medial or lateral side of the knee
Considered knee dislocations
Results from high energy trauma
commonly
Associated injury to patellar and
quadriceps tendon, popliteal artery and
peronal nerve
Investigation: ankle brachial index,
angiography
Treatment: reduction of dislocation
Nonoperative treatment:
Elderly
Low demand,
Comorbidities
Operative treatment: 2 or more
ligaments causing instability
Rehabilitation
Depends on number of ligaments
repaired
Immobilizaion in extension post op

59. COMPLICATIONS
EARLY:
Popliteal artery injury
Common peroneal nerve injury
graft failure
LATE:
Joint instability
Stiffness
Osteoarthritis

60. PROGNOSIS
Depends on the type, number of ligaments and degree
of injury

61. FUTURE TRENDS
Arthroscopic bridge-enhanced ACL repair (BEAR) trial
with a bridging scaffold is ongoing

62. Take home message
Knee ligament Injuries encompass ACL,PCL,MCL and LCL injuries
They result from contact and non contact sports
Clinical evaluation entails history taking, physical examination and
investigations including x-ray which may show avulsed piece of bone at the
site of ligament attachment or partial /complete ligament tear on MRI
Non operative treatment involves protective weight bearing, bracing and
physiotherapy while operative treatment involves ligament repair or
reconstruction

63. CONCLUSION
Knee ligament injuries are common injuries among sportsmen
The mechanism of injury determines the type of ligament
involved
They are a common cause of knee pain and disability
Treatment depends on the type of ligament involved
Rehabilitation following treatment helps optimize function

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Rehabilitation of Sports Injuries. Springer, Berlin, Heidelberg.
https://doi.org/10.1007/978-3-662-04369-1_1
 Hastings DE. Diagnosis and management of acute knee ligament injuries. Can Fam
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